The Host

Julie Rovner KFF Health News @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

After weeks of painstaking negotiations, Democrats and Republicans in the House and Senate agreed to a major year-end package of health bills, including new regulations for drug companies and pharmacy benefit managers, and renewals of programs to combat opioid abuse and prepare for the next possible pandemic. But the effort could be all for naught, as President-elect Donald Trump and his government-cutting adviser, Elon Musk, complained it gave Democrats too much of what they wanted and threatened Republicans who might vote for it with challenges in upcoming primary elections.

Meanwhile, Texas Attorney General Ken Paxton sued a doctor in New York for prescribing abortion pills via telemedicine to a patient in Texas, in the first major test of whether “shield laws” — intended to protect doctors in states like New York where abortion remains legal — can protect against other states’ enforcement efforts.

This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Victoria Knight of Axios, and Alice Miranda Ollstein of Politico.

Panelists

Jessie Hellmann CQ Roll Call @jessiehellmann Read Jessie's stories. Victoria Knight Axios @victoriaregisk Read Victoria's stories. Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories.

Among the takeaways from this week’s episode:

• Congress looked to be on the cusp of passing its government spending bills this week, then Trump spoke out. The package featured robust, bipartisan policies — including things that Trump himself has endorsed, such as reforming the pharmacy benefit manager system. Now, it’s not only those policies, plus key extensions on the Medicare telehealth program, opioids, and more, that Trump has undermined: A government shutdown could also furlough the federal employees helping his team transition ahead of his inauguration next month.
• Meanwhile, Robert F. Kennedy Jr. has been making the rounds on Capitol Hill to gain support for his confirmation to lead the Department of Health and Human Services. And many senators seem surprisingly supportive of his bid. Some are leaning on shared goals such as limiting ultraprocessed foods. In general, Republican senators do not seem too concerned about RFK Jr.’s nomination — despite a track record of opposing scientific consensus on vaccines and supporting abortion rights.
• New government data shows health care spending is up. The recent fatal shooting of an insurance executive has triggered a backlash against the insurance industry, yet the data shows costs are going up due to higher utilization — not necessarily because of factors within insurers’ control. Bottom line: In a system of constant finger-pointing, insurers have earned ire for questionable coverage decisions and lack of transparency — but they’re not the main, or only, culprits of high costs and access problems.
• And, in reproductive health news, the attorney general of Texas is suing a New York doctor for prescribing the abortion pill to a patient in Texas. New York, like other more Democratic states, has a shield law protecting providers, yet this case will be the first test of such a law.

Also this week, Rovner interviews KFF President and CEO Drew Altman about what happened in health policy in 2024 and what to expect in 2025.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: Vox.com’s “The Deep Roots of Americans’ Hatred of Their Health Care System,” by Dylan Scott.

Alice Miranda Ollstein: KFF Health News’ “Native American Patients Are Sent to Collections for Debts the Government Owes,” by Katheryn Houghton and Arielle Zionts.

Jessie Hellmann: KFF Health News’ “How a Duty To Spend Wisely on Worker Benefits Could Loosen PBMs’ Grip on Drug Prices,” by Arthur Allen.

Victoria Knight: Bloomberg News’ “The Weight-Loss Drug Gold Rush Has a Dangerous Prescription Problem,” by Madison Muller.

Also mentioned in this week’s podcast:

• KFF Health News’ “Trump’s Picks for Top Health Jobs Not Just Team of Rivals but ‘Team of Opponents,” by Stephanie Armour and Julie Rovner.
• Health Affairs’ “National Health Expenditures in 2023: Faster Growth as Insurance Coverage and Utilization Increased,” by Anne B. Martin, Micah Hartman, Benjamin Washington, and Aaron Catlin.
• Politico’s “The DOGE Plan That Could Cost Millions,” by Alice Miranda Ollstein.
• KFF Health News’ “Florida Gov. DeSantis’ Canadian Drug Import Plan Goes Nowhere After FDA Approval,” by Phil Galewitz.

click to open the transcript Transcript: End-of-Year Chaos on Capitol Hill

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Dec. 19, at 10 a.m. As always, and particularly this week, news happens fast and things might’ve changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Victoria Knight of Axios. 

Victoria Knight: Hi, y’all. 

Rovner: And Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Hello. 

Rovner: Later in this episode we’ll have my interview with KFF President and CEO Drew Altman, who I’ve asked to give us a very quick review of 2024 in health policy and what he thinks might be in store for 2025. But first, the news. 

So, 24 hours ago when I sat down to write this, I had a whole long list of things Congress was about to pass as part of a pretty big health package attached to a three-month continuing resolution to keep the government running. The current continuing resolution, as a reminder, expires at midnight Friday. After many weeks, Republicans and Democrats negotiated a health package that covers everything from PBM [pharmacy benefit management] reform to extensions of telehealth authority for Medicare to pandemic preparedness and opioid programs. And we will talk about those things in a minute. But please someone try to explain exactly what happened yesterday after the package was unveiled and seemingly ready for majority votes in both the House and the Senate? 

Knight: Yeah, I can take this one because I’ve been there every day for the last three weeks. 

Rovner: Tell us, Victoria. 

Knight: So it’s really been several weeks of negotiation between the House and Senate, a lot of offers back and forth we were reporting on. In one of the original Democratic offers, they were trying to get the ACA [Affordable Care Act] subsidies extended for a year. That fell out, but there was a lot of policies going back and forth. Ended up with a really robust health care package that they released this week and that included some of the things you’re talking about, but notably PBM reforms that would de-link the price of the drug and compensation for PBMs from the price of the drug. That’s a really big policy that’d be for Medicare. And then there was also kind of a rebate pass-through policy that would be sort of a big deal as well. And then also, I think this is a little under-reported, but there is a bill that would basically crack down on drug patent thicketing. So, that had bipartisan support in the Senate. And— 

Rovner: And just real quick, what is that? 

Knight: You know— 

Rovner: You want me to give it a try? 

Knight: Yeah, do you want to give it a try? 

Rovner: Yes, I’ll give it a try. It basically will stop brand-name drugmakers from stacking patents on top of each other so that they can continue to extend the life of a patent that should have expired and allowed for generic competition. Is that— 

Knight: Yes. 

Rovner: I’m looking around. Did I get that right? Yes. People seem to be agreeing that that’s the short explanation. But yes, so there was going to be the PBM stuff that the PBMs hated because they were going to make less money. There was stuff that the drug companies were going to hate, but all of these things would’ve actually addressed drug prices, which the public and Democrats and Republicans say they want. Right? 

Knight: Right. Exactly. And President-elect [Donald] Trump has been really big on saying he also wants PBM reform. And then just really quick also, there’s some really important extender programs that really need to get addressed because they have expiration dates at the end of this month or early next year, but that’s like Medicare telehealth flexibilities, community health center funding. There was, as you mentioned, an opioid reauthorization program, a pandemic preparedness reauthorization program. I’m probably missing some things, but there was a lot in this package. 

Rovner: Medicare cuts for doctors. 

Knight: Yeah, addressing Medicare cuts for doctors. 

Rovner: Although not completely. 

Knight: Also, yeah, averting Medicaid DSH [disproportionate share hospital] payment cuts for hospitals, which has been something that has had to be averted every year. So that’s all in jeopardy now because, yesterday, the package was released officially on Tuesday, and then yesterday once people started going through the bill — it was a big bill. It was about 1,500 pages. Health care itself was about 500. But there were a lot of other things in there, and there was a lot of misinformation going around on social media. But basically Elon Musk started saying he was unhappy with the bill. He was putting things like saying it would have money for a stadium for D.C., which is not accurate. It was just transferring the land from the government to D.C. So— 

Rovner: In case D.C. wanted to have the owners of the football team build a new stadium. 

Knight: Exactly. 

Rovner: At their expense. 

Knight: Yeah, so they were talking about there are a lot of add-ins to the bill, but it wasn’t completely accurate the way they were talking about it. And so, but then a lot of Republicans got on board and were like, I’m unhappy with this as well. And then Trump weighed in and said, I don’t want to have a bill this large. And as far as we know, the latest is that he just wants a clean continuing resolution and to address the debt limit deadline, which is coming up next year. 

Rovner: Now, wait. How did the debt limit get into this? The debt limit isn’t coming up until the middle of next year. 

Knight: I mean, he said his view was that he didn’t want to be stuck with dealing with it, basically. I think he understands that it can be pretty annoying. So he, in his statement yesterday, he said it should be addressed during the Biden administration. And I don’t know why the Biden administration would play ball with that, necessarily. I don’t know if anyone else wants to weigh in to that. 

Rovner: So where are we as of this morning? Jessie, Alice, are you guys following this? 

Ollstein: So, I mean, I think that the chances of a shutdown just went up astronomically. And so everyone is trying to think through: How would a shutdown impact the presidential transition work that’s going on right now? Would agency employees that are right now briefing the Trump landing teams that have only just arrived this week — which is weeks and weeks later than they normally have in past transitions, so they already have a compressed timeline — and would those people be furloughed and not deemed essential and not allowed to do that work? And would that put the transition further behind? 

So we’re really having to think through all of these kind of unprecedented scenarios because of this death by tweet. And while that part is sort of unprecedented, it is a real throwback to the first Trump administration. This dynamic happened all of the time where folks on Capitol Hill hammered out a deal painstakingly over weeks and weeks and weeks, and at the very last minute Trump came in and had issues with it and blew it all up. This happened over and over with lots of legislation. And so while it is a very unique sort of time and other factors, that part is less unique, and, you know, welcome back to this. 

Rovner: To chaos. Yeah, I feel like what’s making my head explode is that all of the stuff that is in this package is bipartisan, by definition. I mean, Victoria, as you said, the Democrats floated the idea of, Let’s extend the ACA subsidies. And yeah, I didn’t think that was going to go anywhere and it didn’t. But everything that’s in here are things that both Democrats and Republicans have been working for this entire Congress. 

Ollstein: Yes. 

Rovner: Is it all going to just end up on the cutting-room floor? 

Knight: Well, and I mean, we have to remember also the Senate is still in Democratic power for now, for now. So you need Democratic votes. And also because the House Republican Caucus is so unruly and they have such a slim majority, anything that [Speaker] Mike Johnson usually puts on the House floor, it’s difficult to pass with all Republican support, just the way that his conference is. And so he really needed Democrats on this bill, and that’s why there was bipartisan negotiation. And he needs Democrats in the Senate as well. 

So yeah, they’ve been painstakingly, for health care, there have been offers going back and forth for weeks to kind of hammer this out and make sure both sides had things that they were really excited about. And PBR reform has been really bipartisan. In this Congress it’s probably been the thing both chambers, both sides have really agreed on the most, and so it is possible that it could just all go to the wayside. I’ve been texting aides this morning, and their view is frustration, obviously, but also it may just end up being where the health extenders get done, the ones that have these expiring deadlines. But other than that — which is what we’ve seen with past continuing resolutions — but anything extra may just fall to the wayside. And all of this work in the 118th [Congress] and this negotiation of the past three weeks may be kind of for naught. 

Rovner: Well, one last tidbit before we leave this, because it was just too delicious. One of the things in this bill, and no one’s obviously taking credit for it, would be a small increase in salary for members of Congress, which they haven’t had since 2009. It’s not a 40% increase, as some people have been saying on social media. It’s like $7- or $8,000, from $174,000 to $181,000. 

But there’s also a get-out-of-the-ACA-free provision, which I found fascinating. Now, for those of you who weren’t around in 2010 when Democrats passed the Affordable Care Act, [Sen.] Chuck Grassley, Republican from Iowa, said, Well, if we’re going to make other people do this, we should do it, too. And the Democrats basically called his bluff and said, OK, members of Congress are going to have to buy their insurance not through the Federal Employees Health Benefits plan but through the ACA, and staff, too. Although it wasn’t all staff. It was chunks of staff. And that’s what happened. And apparently what’s in this bill is that the members can go back into the Federal Health Employees Benefits plan if they want, but not the staff. Does anybody have any idea where this came from? 

Knight: So I actually did some reporting on this yesterday, as well. It was funny, because I had heard a rumor about how it may have happened, but then when I called up House leadership in both offices, they both demanded to tell me it was a bipartisan agreement. They didn’t want to blame either side. So I thought that was really interesting because that means Minority Leader [Hakeem] Jeffries agreed to having this ACA opt-out for members. I might — assuming it was probably in negotiation for something else — because I don’t think it’s as much a Democratic priority as a Republican priority. I mean, this bill’s all falling apart, so it may not happen, but if it somehow stayed into the bill, yeah, members could go back to the Federal Employee Health Benefits program, which is kind of seen as a cushier health insurance, whereas staff would have to stay on the ACA exchange. So I know that caused some consternation with staff yesterday, but who knows if it’ll happen in the final bill that we see. 

Rovner: I got a frantic emergency email Tuesday night right as the bill came out from somebody who’s keeping a close eye on that and who is not a staffer. So, I mean, why wouldn’t they want to be on the exchange? I mean, they do still. They did arrange it so they get their subsidy. Is it just more trouble to sign up through the exchange, or are there better plans available maybe through the federal plan? 

Knight: I mean, I don’t know. That wasn’t immediately clear to me. I think Republicans just don’t like ACA health insurance, clearly. And so they got tired of having to be on ACA health insurance. That was kind of the vibe I was getting. And they want to go back to what they view as a better health care plan for the Federal Employee Health Benefits. 

Rovner: Or maybe they’ll know they’ll have coverage if they get rid of the ACA. We will see. All right. Well, looking ahead to the incoming Trump administration, which feels like is already in charge, Robert F. Kennedy Jr., Trump’s choice to lead the Department of Health and Human Services, made the rounds on Capitol Hill this week. What, if anything, did we learn about the likelihood of this nomination making it over the finish line? 

Ollstein: Yeah, what’s been really striking to me is how both the Republican senators he’s meeting with seem to be sort of surprisingly flexible on their views and fine with this former Democrat environmentalist, who at times has supported abortion rights and at other times has not, and don’t seem to have strong objections. I think this is a very sort of Trumpian thing where if this is Trump’s guy, then they’re falling in line. And you also see on RFK’s side, he is changing his tune on stances he’s taken in the past on vaccines, on abortion, and in order to give assurances. And so you’re seeing sort of both sides of this equation bending to make it work. And we haven’t seen strong opposition. I do think it’s interesting that he is not meeting so far with any Democrats or even moderate Republicans, as Jessie pointed out. 

Rovner: Although he has some Democratic support. I mean, we’ve seen, obviously, somebody who isn’t going to vote, but Gov. [Jared] Polis in Colorado. I think [Sen.] Cory Booker from New Jersey seems to be. I mean, there are some who like, obviously, some of his stances on things like ultra-processed food and Big Pharma. It’s interesting because he is this sort of kaleidoscope of positions, although I will say there does still seem to be some confusion about his vaccine position. Much has been made of his lawyer petitioning the FDA to withdraw approval of a polio vaccine. And both RFK Jr. and Trump say they don’t want to take vaccines away from anyone who wants them. But that’s not how vaccines work. You can’t really have some people vaccinated and some not when it comes to diseases that are contagious between people, right? 

Ollstein: Yes. It’s about the recommendations. It’s about using the bully pulpit and the position he would be in to encourage vaccinations. So it’s not about banning them or taking them away or making them unavailable. There’s a lot that could happen, including policy levers they could pull that would dictate what is and isn’t covered by insurance. That would have a huge impact on whether people get vaccinated or not. So vaccination rates are already abysmally low, as we’ve seen, and just think about how much worse they would get if people had to pay out-of-pocket and couldn’t get them covered by insurance. 

Rovner: Well, I have a story out this week with my colleague Stephanie Armour about how these various presumptive nominees to head the big HHS agencies under RFK Jr. aren’t just rivals but actual opponents when it comes to things like vaccines and abortion and even obesity drugs. If all these people actually get confirmed to these jobs, could there just be a big policy pileup like we’re seeing with the CR [continuing resolution]? They’re so busy fighting with each other that nothing might happen? Victoria, you’re nodding. 

Knight: I mean, I think it’s so hard to predict with this administration what will happen next, but I certainly think that we saw — and I also think the second Trump administration seems like it’s going to be a little different than the first, but including some hallmarks of the first one — but I think what we saw in the first one was that there was sometimes some dysfunction within the agencies. There was difficulty actually achieving some of President Trump’s policy goals just based on how they drafted executive orders or different things like that. So I don’t know if we’ll see that again this time, but I do think it’s possible. 

Especially important to note that most of these people do not have federal government experience leading agencies or even working in agencies before, and so there is also a learning curve for that and understanding how an agency works and what’s actually feasible to do and what’s within your power to do. Some people have hypothesized, maybe it’ll put the people under them in a stronger position of power. So maybe it’s more important to look at the staffing under them. But first let’s see if they get confirmed, I guess. 

Rovner: Yeah, one thing at a time. Well, in other health news this week — and there was other health news this week — we learned that in 2023, health spending jumped by 7.5% to a total of 4.9 trillion, with a T, dollars. That was actually a big jump from 2022, when spending rose a relatively modest 4.6%. The actuaries at CMS [the Centers for Medicare & Medicaid Services] who do this analysis every year said the main reason was higher utilization resulting from more people having insurance, which is kind of objectively a good thing. Prices, on the other hand, went up pretty fast, too, an average of 3% after a year in which they rose 7.1%. That is not what’s so good, and it helps explain the continuing backlash against the insurance industry that’s sparked by the shocking midtown Manhattan shooting of United Healthcare CEO Brian Thompson earlier this month. New York prosecutors have now charged Luigi Mangione with first-degree murder and terrorism. But is this anger aimed at insurance companies even deserved? When you read the CMS analysis of health spending and what’s driving it, insurance companies are not the key drivers of high health care costs. They’re just, if you will, the middlemen here. 

Hellmann: I have this thought a lot. It turns out that insurance companies might not be great at controlling costs. They just don’t have the market power in some circumstances to negotiate with these massive health systems. But it’s always been like this. It’s hard to view the hospital in your hometown as the bad guy. But I definitely do think there are circumstances where insurance companies do make decisions that are questionable, especially as we see more and more use of AI or decisions being, like prior authorizations, decisions being made by who may or may not have the knowledge to make those decisions. And you see this a lot when denials get appealed and then the insurance company says, Oh, OK, we’ll approve it. So it’s like, well, then why didn’t you just do that the first time? It’s just very frustrating for people, especially doctors. Doctors hate this kind of system. 

Rovner: Yeah, and we have obviously, on this podcast, talked a lot about a lot of good journalism done about United Healthcare writ large, not even so much the insurance company but the other parts of the behemoth that is UnitedHealth Group. So insurers are not blameless in all of this, but they are probably not the sort of main bad guys that I think a lot of the public thinks they are. I think it just gets increasingly difficult to explain. 

Well, turning to abortion, which is definitely still a thing, Texas Attorney General Ken Paxton continues to up the ante, as it were. Now he’s suing a doctor in New York for prescribing abortion medication for a patient in Texas, even though New York has a shield law to protect her — “her” being the doctor, not the patient. This is the first frontal attack we’ve really seen on shield laws, right? Although I guess we’ve been expecting it, Alice? 

Ollstein: Yeah, everyone has been expecting it. I mean, basically everyone has been expecting that anti-abortion officials and activists are going to go after the remaining pathways people have in states with bans to still obtain an abortion. So that is travel out of state, the patient traveling out of state, and that’s the pills traveling in-state. And so there are ongoing lawsuits tackling both of those right now. And this is the first to really go after this practice of shield laws, which have been proliferating in blue states and have really surged to make up a big share, according to groups that track these things like the Society of Family Planning, that a big share of all abortions that are happening are due to these shield laws and telehealth. And so— 

Rovner: It’s one of the reasons we’ve seen that even though there are fewer places to get procedural abortions, the number of abortions isn’t going down. 

Ollstein: Yes. Exactly. Exactly. And so I think we don’t know how courts are going to treat these, and we don’t know how enforceable such bans could be, but I think this has people really nervous. And I think it just shows the flimsiness of the leave-it-to-states platform that Trump and many Republicans ran on, because this is inherently an interstate issue and leaving it to states is never going to be a stable solution for anyone on either side of this issue. 

Rovner: It’s certainly going to keep the courts busy. And while this case is likely to get to the Supreme Court eventually, although it’s many, many steps away, the court this week did accept its first abortion case of the term challenging South Carolina’s right to ban Planned Parenthood from providing non-abortion services to Medicaid recipients. Alice, what is this case about? 

Ollstein: Yeah, so there are several cases out there regarding this very issue. This has been an issue for years and years where states want to kick Planned Parenthood out of their Medicaid programs. And the question is whether that clashes with the statute that says that patients, Medicaid patients, should have their free choice of provider, if they want to go to Planned Parenthood for — again, this is non-abortion services — if they want to go to Planned Parenthood for an STD test or birth control or whatever, that they should have the right to do that. 

Now, South Carolina and several other states, Texas, several other states, have been saying, Sure, but they have their free choice of qualified providers, and we argue that Planned Parenthood should not be considered a qualified provider, because of their abortion work and other things. So this was expected to go to the Supreme Court sooner or later because there have been circuit splits on this where some circuits have ruled in favor of some states, some circuits have ruled in favor of Planned Parenthood. And so it was seen as only a matter of time, but the abortion rights community is very anxious that the Supreme Court took up this case at all because it shows that they are considering that there is a possibility that they will rule that states would be allowed to do this. So this comes amid talk of federally cutting Planned Parenthood’s funding, and so this would be cutting off yet another stream of support in terms of state Medicaid funding, which is separate. 

Rovner: And obviously we’ve been talking about inability to get services, non-abortion reproductive health services, which this would also affect. Well, meanwhile one of the things that, as you mentioned, we are expecting from the Republican-controlled Congress in 2025 is an effort to exclude Planned Parenthood from participation, not just in Medicaid but in the Children’s Health Insurance Program and the Title X Family Planning Program. This is going to be advertised as a budget saver, but it might not be. Right? 

Ollstein: Yeah. So I wrote this week about the push on the right to defund Planned Parenthood. This has been publicly endorsed by the “DOGE” [“Department of Government Efficiency”] folks that are recommending cuts to the administration. Speaker Mike Johnson has said that this is something that he wants to do. And I just surfaced an old CBO [Congressional Budget Office] report from the last time this was discussed, showing that cutting Planned Parenthood funding would actually cost the government more money because people would lose access to birth control and have more children than they wanted to have and that would cost Medicaid a lot more than providing that birth control through Planned Parenthood. And I acknowledge in the piece that the people who want to defund Planned Parenthood are not just sort of budget hawks. They also are ideologically opposed to the organization. And so they presumably would not mind that it would cost more. But putting this in the sort of “Department of Government Efficiency” bucket, we should question that. 

Rovner: Yeah, this will be one of, I think, many issues that we will be watching closely in 2025. Well, finally this weekend, I’ve been trying to get to this story for the last three weeks, and since this is the last podcast of the year, I didn’t want to wait anymore. Remember that really popular idea to get lower drug prices by importing drugs from Canada along with the Canadian price controls? While after much to-ing and fro-ing, Florida finally got permission to start a re-importation. And nearly a year later, according to my KFF Health News colleague Phil Galewitz, it still has yet to launch. 

Colorado has also been trying to get a program off the ground, but apparently it hasn’t been able to find a drugmaker in Canada that’s willing to sell drugs to them. I feel like this is one of those things that always sounds good and enjoys strong bipartisan support but never actually works as advertised — that when it comes to health care, simple is almost never the answer or we would’ve done it already. 

Ollstein: Oh yes. Yeah. There is no one weird trick to solve drug prices, and importation falls into that category. I mean, just the population of Florida is enough to overwhelm the system of another country, let alone the population of the United States. And we really can’t outsource our inability to tackle the underlying causes of these prices and just sort of mooch off other countries’ systems that actually negotiate to bring it down. And so I think this is one of those things that sounds good in theory and falls apart a little in practice, although I guess we would need to see maybe more attempts on this front to really come to a conclusion. 

Rovner: Although, she says with a sigh, the package that’s now on ice in Congress might actually have some impact on lowering drug prices, but we’ll have to see what happens to that. All right. That is the news for this week. Now we’ll play my interview with Drew Altman, and then we’ll come back and do our extra credits. 

I am so pleased to welcome back to the podcast Drew Altman, president and CEO of KFF and, yes, my boss, but also the person whose judgment I have trusted on health policy since long before I worked here. Drew, thank you for joining us today. 

Drew Altman: Always happy to join our flagship podcast, Julie. It’s a privilege. 

Rovner: So since this is our last podcast of 2024, I thought we could do a quick review. What’s the biggest health policy takeaway for you from this year? An awful lot of things have happened. 

Altman: It was a fork-in-the-road election. The biggest health policy event this year was something called an election, which was about a fundamental question of direction in health care — continuing to build incrementally on the public programs and what we’ve been doing, making some targeted progress in access and in affordability, versus a very different direction, scaling back the federal role in health care and potentially very significant cuts in federal spending, with a lot of that focusing, we think, on the Medicaid program. But all that is still a story that has to unfold, and it remains to be seen exactly how it will unfold. 

Rovner: Two things have happened since the election that seem important to what may happen next year — obviously the very unfortunate targeted killing of a health insurance executive and now news just today that health care spending really spiked in 2023. We haven’t seen big increases like this in a while. How is that going to sort of change the atmosphere around health policy going forward? 

Altman: Well, the killing was a major event and a horrible event. Whether it is a tipping point in terms of patients’ rights and consumer protection pre- prior authorization and insurance denials, or just a news cycle, I think really remains to be seen. Because to address that issue requires regulatory action to protect consumers. And it really does not appear that that’s in the offing with Republicans in control in the Congress. They don’t really have an appetite for that. And the states, there’s some action in the states, but they have a limited ability to address the issue, because they can’t really touch self-insured plans. So maybe we’ll make some incremental progress, but I don’t really, sadly, think we’re at a tipping point on that issue. 

Rovner: We’ve both been at this for several decades now. The health care system has only gotten more complex, I think, since you and I started looking at it. How much harder is it to explain this with the rise of mis- and disinformation that’s now so rampant? 

Altman: Well, it’s a lot harder. Experts are not trusted. Facts don’t have the impact they used to have. But it’s funny, the one place where they still play a role is when there’s debate about legislation. And there still is a Congressional Budget Office, and legislation still is scored. And while that’s a little bit more funky than it used to be, it still happens. And so when you get down to legislative debates and as the new administration takes shape and ideas become legislative proposals, then numbers and facts will still matter about big proposals to change, for example, the Medicaid program, about what happens if you don’t extend ACA premium subsidies, about what happens if you cut back the matching rate for the Medicaid expansion in 40 states, about what really happens if you impose Medicaid work requirements in every state, about what would happen if you try and block-grant the Medicaid program, about any of the big proposals that we could see come down the track. 

So yeah, we’re living in a world of misinformation, but when you get to the legislative arena, still facts and numbers and analysis, maybe they don’t matter as much as they used to, but they still matter. 

Rovner: What about in the public health sphere? I mean, we’re looking at the potential of an HHS secretary who may or may not believe in vaccines and the potential of a bird flu pandemic. Those don’t seem to be wonderful things that could go together. 

Altman: Well, we’ll see who is the HHS secretary. That’s still a story that is unfolding. That is really troublesome, where if you have public leaders who fan the flames of misinformation, it empowers those who are out there already who are spreading misinformation, and that’s a problem. On the other hand, one thing I do worry about is that so much attention will focus on these shiny objects of these controversial public leaders, it will take the media’s attention off of, and everyone’s attention off of, the even larger changes that might come in the big public programs, particularly Medicaid and the ACA, that will affect tens of millions of people at a time when the big problem Americans are having in health care is the struggles they’re having paying their medical bills. So those are real issues, but everyone needs to keep their eyes on those programs, not just the controversies, which are easier to get your head around and will make news. 

Rovner: Is there an issue that you think is flying too much under the radar? I feel like, I’ll offer out mine. I think that the fallout from the Supreme Court’s decision about federal agencies and their authority to make regulations, we have no idea how that’s going to play out, and it could be enormous. 

Altman: Well, I think that’s one issue. One of the things that strikes me, as you go out into the health care system and you don’t hear much discussion about what’s going to happen with Medicaid or what’s going to happen with the Affordable Care Act or the issues that we’re so focused on at KFF or will be the focus on Capitol Hill. You hear about an entirely different set of issues. AI is the rage. Still, delivery and payment reform and value is the fad. That’s maybe fading a little bit, but it’s still the focus. 

And so there is this striking discontinuity between what the health policy world is focused on, what we will be focused on when we look at health care legislation, and what the health care system is focused on. And that’s a little bit troubling to me because the decisions that will be made in Washington and in state capitals about health policy, those are the decisions that will really affect people. The other stuff affects doctors, hospitals, their bottom line, health care delivery. But what will happen in the next year, maybe two years with the big public programs is really what will affect tens of millions of people. 

Rovner: Well, we will be there to watch them. Drew Altman, as always, thank you for joining us. We will talk to you in 2025. 

Altman: Thank you very much, Julie. 

Rovner: OK, we are back. And now it’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We’ll put the links in our show notes on your phone or other mobile device. Jessie, why don’t you go first this week? 

Hellmann: My extra credit is from KFF [Health] News, an article by Arthur Allen [“How a Duty To Spend Wisely on Worker Benefits Could Loosen PBMs’ Grip on Drug Prices”] about a lawsuit filed against Johnson & Johnson but probably not for the reason you think. It was filed by an employee of Johnson & Johnson who argued that the company is basically not doing enough to control drug costs in the health plan that they offer their workers. The employee argues that they’re really being exposed to high payments for prescription drugs, high premiums, high deductibles, and they have a duty under ERISA [the Employee Retirement Income Security Act] to make sure that they’re prudently managing these health plans. So I think it’ll be interesting to see the outcome of this. I think we all see our premiums go up every year in the employer market and wonder: What are our employers actually doing about that? A lot of them just contract with brokers who may or may not be getting steered by PBMs and others in the industry to select specific plans and plan designs. So it’d be really interesting to see where this goes. 

Rovner: Super interesting. Interesting lawsuit, interesting story. Victoria. 

Knight: My extra credit today is from Bloomberg News, and the title is “The Weight-Loss Drug Gold Rush Has a Dangerous Prescription Problem.” It’s by Madison Muller, and it was kind of just chronicling some real-life people that struggle with anorexia and eating disorders and how easy it is for them to access Ozempic or Wegovy or some of the other weight loss drugs, the injectable weight loss drugs that we’ve really seen a boom in people accessing over the last couple of years. But it’s showing that with telehealth companies, some of these telehealth companies, it’s just so easy to get these drugs. You can just lie about your weight, you can lie about your BMI [body mass index], and there’s just not much oversight, honestly, according to this news article, at least. 

And of course, the companies push back and say: We have doctors review this, and we have them answer safety questions. And if they’re not answering honestly, that’s on the patient. But it talked about the real-life effects of some people who then already struggle with eating disorders, access these drugs, and then kind of relapsed and had to go into inpatient treatment. And now it’s just something they’re going to struggle with because they know how easy it is to access these weight loss drugs. So I thought it was a really interesting look at that and some really great talking to real people who have been affected. 

Rovner: Alice. 

Ollstein: I have a piece [“Native American Patients Are Sent to Collections for Debts the Government Owes”] from Marketplace that is very grim. It’s about Native Americans who get their health care through the IHS [Indian Health Service] who are receiving these big medical bills and going into medical debt when they are not supposed to. It is supposed to be fully covered. So those bills should be going to the federal government, not to patients, and yet they are going to patients. And not only that, Native American-majority communities have medical debt in collections at nearly twice the national average. And so this is going into why that is, what it means, how underfunded and understaffed IHS is, and this is yet another injustice faced by this community. So hopefully this sheds some light on it. 

Rovner: Yeah, really good, intrepid reporting by my KFF Health News colleagues for Marketplace. My story this week is from Dylan Scott at Vox. It’s called “The Deep Roots of Americans’ Hatred of Their Health Care System.” And it’s a really good take that I’ve been kind of rolling around in my head for a while now that basically every single player in the health care system has made it the mess it is, mostly by pointing fingers at somebody else. Drugmakers point at PBMs, doctors point at insurers, insurers point at hospitals and doctors, and patients point at everyone and everything for a system that’s both too expensive and impossible to navigate. How do we fix it? I don’t know. I don’t think Dylan does, either. But I don’t think we can even start until we broaden the conversation to take in the whole picture. 

OK, that is this week’s show and our last for 2024. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks again this week to our temporary production team, Taylor Cook and Lonnie Ro, as well as our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X occasionally, @jrovner, and increasingly at Bluesky, @julierovner.bsky.social. Where are you guys these days, Victoria? 

Knight: I am still on X, and I’m @victoriaregisk. 

Rovner: Jessie. 

Hellmann: I am on X and Bluesky, @jessiehellmann. 

Rovner: Alice. 

Ollstein: I am on X, @AliceOllstein, and on Bluesky, @alicemiranda. 

Rovner: We will be back in your feed next year. Until then, be healthy. 

Credits

Taylor Cook Audio producer Lonnie Ro Audio producer Emmarie Huetteman Editor

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This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.